MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 1 of 9
Admit Date: ______________
Identifying Information
Child Agency of Primary Responsibility
Name: _____________________________________ DOB: _____________ Age: ________ Refer to “MH 525: Contact Information”
form for detailed contact information.
Other Names Used: ____________________________________ Gender: Male Female DMH DCFS
Ethnicity: ________________________ Preferred Language: ________________________ Probation School District
Referred by (Name & Number): __________________________________________________ Others ______________________
Biological Parents
Mother’s Name: _______________________________________ Father’s Name: __________________________________________
Marital Status: ________________ DOB: ____________ Marital Status: ________________ DOB: _______________
Address: _____________________________________________ Address: ________________________________________________
Phone: _________________ Work: ______________________ Phone: ___________________ Work: _______________________
Preferred Language: ____________________________________ Preferred Language: ______________________________________
Interviewed: Yes No Interpreter Used: Yes No Interviewed: Yes No Interpreter Used: Yes No
Language Used for Interview: ____________________________ Language Used for Interview: _______________________________
Primary Caregiver (Complete only if Biological Parent is not the Primary Caregiver)
Adoptive Guardian Foster Kinship/Relative Group Home Other
Name: _______________________________________ Relationship to Child: ________________________ DOB: ______________
Address: ________________________________________________________________________________________________________
Marital Status: __________________ Phone: ___________________ Work: _________________________________________
Preferred Language: _________________ Language Used for Interview: _______________________ Interpreter Used: Yes No
Reason for Referral/Chief Complaint
Why Referred?
Current primary
symptoms/behaviors
impairments in life
functioning
Describe onset,
duration, and
frequency
Strengths of child and
family:
Athletics, Clubs
Affiliations,
Social, Personal,
Relational
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 2 of 9
Medical and Psychiatric History
History of Presenting Problem
Symptoms/Behaviors
How a problem
Caregiver perception
of cause
Attempted interventions
and responses
Relevant Factors
Environment
(School/Home)
Relationships
(Loss/Separation)
Traumatic Events
Sexual/physical/emotional
abuse
Sleep Patterns
Eating Patterns
Hygiene Changes
Problem suggestive of:
MR
LD
PDD
ADD & Disruptive
Behavior
Feeding & Eating
Tic
Communication
Elimination
Other
Schiz/Psychotic
Mood
Anxiety
Additional Problem Areas/Associated Behaviors
Peer Problems
Other
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 3 of 9
Medical and Psychiatric History (continued)
Prior Mental Health History
Suicidality/Homicidality
# of attempts, method
Interventions
When
Facility (Name or Type)
Type of intervention
Duration
Medication: dosage
response, adverse
reactions
Recommendations
Response to treatment
Parent and Child
Satisfaction
Records requested from: __________________________________________________
Substance Use Overview & Attitudes/Exposure (family & peers experience)
MH554 Substance Use Self-Evaluation Completed: Yes No Explain: __________________
MH552 Parent/Caregiver Questionnaire Completed: Yes No Explain: __________________
(For any Yes on either above form or for use reported from any other source,
complete MH553 Child/Adolescent Substance Use Assessment)
Medical History
Illness (Acute/Chronic) Pediatrician Name: _______________ Phone: ______________
Medications Last Exam: _______________ Glasses: Yes No Braces: Yes No
Allergies
Accidents
Head Injuries
Seizure/other neurological
Pregnancy
Sexually Transmitted
diseases
HIV
Vaccinations
Hospitalizations/Surgeries
Vision/Hearing
Dental Health
Records requested from: __________________________________________________
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 4 of 9
Medical and Psychiatric History (continued)
Developmental History
Neonatal: Prenatal Care? ___________________________ Term: Mos. _____________ Birth Wt ___________
Place of Delivery: _________________________________ Age of Mother: _____ Age of Father:_____ Marital Status: ___________
Did Mother use alcohol, cigarettes, drugs? Specify: ______________________________________________________________________
Illness, accidents, stresses during pregnancy or at the time of pregnancy:
_________________________________________________________________________________________________________________
Type of Delivery: ________________________________ Duration of Labor: _____________________________________________
Post Partum complications: _________________________________________________________________________________________
Comments (include family and environmental stressors during pregnancy and at birth):
______________________________________________________________________ __________________________________________
Developmental Milestones Environmental Stressors
(Describe if not within normal limits) Moves; schools; losses of fam/friends, changes
in fam composition; SES, lifestyle; exposure to
fam conflict/violence; major illnesses; abuse;
placements, etc.
Infancy (0-3) Infancy (0-3)
Motor – sit, crawl,
walk
Speech; Eat; Sleep
Toilet training
Coordination
Temperament
Separation
Early Years (4-6) Early Years (4-6)
Social Adjustment
Separation
Sexual Behaviors
Self-Care
Latency (7-11) Latency (7-11)
School adjustment
Peer & adult
relations/friends
Interest/hobbies
Impulse control
Self-Care
Adolescence (12-on) Adolescence (12-on)
Separation/individ.
Sexual orientation
Sexual behavior
Gender identity
Relationships/Support
Systems
Independent funct.
Moral development
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 5 of 9
Other Information
School History, Current Status & Aspirations
Type of School
Academic Performance School: ____________________________________________ Grade Level: ______________
Grade Retention Special Education: ____________________ Special Classes: _________________________________
School Changes:
Current/Past IEP and Dates: _______________________________________________________________
Age & Grade
Attitude/Behavior AB 3632: Yes No Services: ____________________________________________________
Attendance/Truancy
Suspension
Vocational History, Current Status & Aspirations
Jobs
ILP Programs
Training
Job Related Problems
Career Interests
Juvenile Court (Delinquency) History
Arrests/Offenses
Tickets/Warnings
Probation/Stipulations
Current/Prior
Incarceration
Placement
Child Abuse & Protective Services History
Nature of
Allegations/Abuse
Age of occurrence
Offender
DCFS or Police
Intervention
Dependency Court or
Criminal Court action
Child Response
Parents response to
disclosure
Placements and type
Services and type
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 6 of 9
Current Living Situation
Be sure to address each Biological Adoptive Guardian Foster Kinship/Relative Group Home Other
bolded category below
Family Composition
Siblings
Stepparents/others
Grandparents
Extended Family
Ethnicity/Culture
Education
Occupation
Socio-Economics
Religious Affiliation
Family History
Medical
Psychiatric
Alcohol/Drug
Legal/Criminal
Family Relationships
(current and
intergenerational)
Quality of attachment
(attunement, balance
& congruence)
Disciplinary Style
Conflict/Violence
Problem Solving
Family Strengths
Clt/Fam perspective
Writer’s perspective
Family Needs
Clt/Fam perspective
Writer’s perspective
Child & Family/Significant Other Stated Needs & Expectations within the Context of their Culture
What are family
members/child:
Expecting of MH
Expecting from
interagency system
Willing to contribute
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 7 of 9
Relevant Past Living Situation (Complete only if client has had more than one Living Situation)
Be sure to address each Biological Adoptive Guardian Foster Kinship/Relative Group Home Other
bolded category below
Family Composition
Siblings
Stepparents/others
Grandparents
Extended Family
Ethnicity/Culture
Education
Occupation
Socio-Economics
Religious Affiliation
Family History
Medical
Psychiatric
Alcohol/Drug
Legal/Criminal
Family Relationships
(current and
intergenerational)
Quality of attachment
(attunement, balance &
congruence)
Disciplinary Style
Conflict/Violence
Problem Solving
Family Strengths
Clt/Fam perspective
Writer’s perspective
Family Needs
Clt/Fam perspective
Writer’s perspective
Family/Child’s Current Visitation & Involvement Plan and Schedule
(Complete only if client does not reside with family of origin)
What is the family’s current
court-ordered visitation plan?
Biological Parents
Stepparents/Siblings
Extended Family
Frequency of visits, length,
need for monitoring
Engagement in child’s assessment
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 8 of 9
Mental Status
Provide a word picture of this child based on your observations.
Be sure to address relevant features from each bolded category in the left column.
Appearance
Dress, grooming, unusual
physical characteristics
Behavior
Activity level, mannerisms, eye
contact, manner of relating to
parent/therapist, motor
behavior, aggression,
impulsivity
Expressive Speech
Fluency, pressure, impediment,
volume
Thought Content
Fears, worries, preoccupations,
obsessions, delusions,
hallucinations
Thought Process
Attention, concentration,
distractibility, magical thinking,
coherency of associations,
flight of ideas, rumination,
defenses (e.g. planning)
Cognition
Orientation, vocabulary,
abstraction, intelligence
Mood/Affect
Depression, agitation, anxiety,
hostility absent or unvarying,
irritability
Suicidality/Homicidality
Thoughts, behavior, stated
intent, risks to self or others
Attitude/Insight/Strengths
Adaptive capacity, strengths &
assets, cooperation, insight,
judgment, motivation for
treatment.
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
MH 533 CHILD/ADOLESCENT
Revised 9/07 INITIAL ASSESSMENT Page 9 of 9
Summary and Diagnosis
I. Diagnostic Summary: (Be sure to include significant strengths/weaknesses, observations/descriptions, symptoms/impairments in
life functioning i.e. Work, School, Home, Community, Living Arrangements, etc)
II. Admission Diagnosis (check one Principle and one Secondary)
Axis I Prin Sec Code __________ Nomenclature ______________________________
(Medications cannot be prescribed with a deferred diagnosis)
Sec Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Axis II Prin Sec Code __________ Nomenclature ______________________________
Sec Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Axis III ___________________________________ Code ___________
___________________________________ Code ___________
___________________________________ Code ___________
Axis IV Psychological and Environmental Problems which may affect diagnosis, treatment, or prognosis
Primary Problem #: ___
Check as many that apply:
1. Primary support group 2. Social 3. Educational 4. Occupational
environment
5. Housing 6. Economics 7. Access to health 8. Interaction with legal
care system
9. Other psychosocial/environmental 10. Inadequate information
Axis V Current GAF: ______ DMH Dual Diagnosis Code: __________
Above diagnosis from: _______________________________ Dated: _________
III. Disposition/Recommendations/Plan:
IV. Signatures
__________________________________ __________ ________________________________ __________
Assessor’s Signature & Discipline Date Co-Signature & Discipline Date
This confidential information is provided to you in accord with State and
Federal laws and regulations including but not limited to applicable Welfare and Name: MIS#:
Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without prior written
authorization of the client/authorized representative to who it pertains unless Agency: Provider #:
otherwise permitted by law. Destruction of this information is required after the
stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health
CHILD/ADOLESCENT INITIAL ASSESSMENT
